Assessing malignant central airway obstruction in palliative care

Malignant central airway obstructionMallow, 2018Mudambi, 2017Todd KH, 2016 is airflow obstruction of the trachea or mainstem bronchi, and is most commonly caused by primary lung cancer.

Malignant central airway obstruction is a medical emergency and can be life-threatening. Depending on the patient’s goals of care, immediate referral to the closest emergency department may be considered for investigation and management.

Presentation of malignant central airway obstruction depends on the severity, location and duration of the obstruction. Obstruction can occur from extrinsic compression or intrinsic invasion of the airway.

Symptoms are nonspecific; clinical features may include breathlessness, orthopnoea, cough, haemoptysis, wheeze, and symptoms of lower respiratory tract infection. Malignant central airway obstruction is often mistaken for common conditions such as an exacerbation of chronic obstructive pulmonary disease.

Stridor or drooling indicates malignant central airway obstruction is becoming life-threatening.

Urgent investigations for malignant central airway obstruction may include:

• chest X-ray
• computed tomography (CT) of the chest, provided the obstruction is not life-threatening (ie the patient has no signs of stridor or drooling)
• bronchoscopy—can provide diagnostic information on obstruction type and tissue diagnosis, and offers a range of therapeutic modalities for acute management.

Consider the safety of all investigations, including the risk of deterioration (eg lying down for a computed tomography [CT] scan can immediately destabilise the airway).